The Rosenhan Experiment: Psychiatry, Bias & Misdiagnosis

Dr. Rosenhan's "On Being Sane in Insane Places" uses information collected by his undercover
research team to examine psychiatric diagnostic practice.

In his 1973 article, “On Being Sane in Insane Places,” psychologist David Rosenhan asked, “If
sanity and insanity exist, how shall we know them?” The article was a discussion of an
experiment Rosenhan himself conducted in the same year, in which he and eight other “sane”
people checked into psychiatric hospitals under pseudonyms and reported specific symptoms of
mental illness but behaved entirely normally after being admitted.

The disturbing results of the study indicated that the majority of medical professionals in the
mental health field will identify previously undiagnosed and “sane” people as mentally ill when
primed by the presence of psychiatric labels and diagnoses.

Being Sane: Part 1 of the Rosenhan Experiment

Rosenhan chose eight pseudopatients of varied backgrounds, ages, genders and professions and
sent them to a variety of hospitals in five different states. The hospitals were not made aware in
any way of Rosenhan’s experiment or the presence of the pseudopatients. Pseudopatients made
appointments at their hospitals under pseudonyms, claiming that they were hearing voices that
said “empty,” “hollow” and “thud.”

Pseudonyms and the reported hallucinations were the only falsified information – pseudopatients
were to be honest about their emotions, histories, relationships and behaviors. After being
admitted, pseudopatients stopped pretending to hear voices, told staff that they felt fine and no
longer experienced any symptoms, and behaved normally.

Pseudopatient Experiences in Psychiatric Hospitals

All pseudopatients except one were admitted with diagnoses of schizophrenia, and all were
discharged with diagnoses of “schizophrenia in remission.” This means none of the
pseudopatients were discovered to be sane and that their “normal” behavior was interpreted to be
evidence that their schizophrenia was responding to treatment. Before being discharged,
pseudopatients stayed an average of 19 days, and one stayed for 57 days.

Rosenhan’s team of researchers were told that they had to be released on their own, Rosenhan
writes, “by convincing the staff that [they were] sane.” This means they had incentive to behave
in a friendly, cooperative and otherwise normal manner. Despite the fact that they conducted
themselves inside the hospitals in the same way that they did in their daily lives, all of the
pseudopatients were believed to be mentally ill and treated as such.

Writing Behavior: Normal Interpreted as Abnormal in Psychiatric Hospitals

One notable misperception of the staff in regards to the research team’s non-existent psychoses
was the interpretation of their “writing behavior.” Because they were conducting a research study,
all of the pseudopatients took copious notes during their stays in the hospitals. Many of their
fellow inpatients remarked on their note taking and wondered whether the pseudopatients were
impostors posing as fake patients.
Staff members, on the other hand, believed that the “writing behavior” was related to the
schizophrenia they believed the pseudopatients had and mentioned this writing behavior in their
observations of their patients, citing it as evidence of their psychosis. However, Rosenhan notes,
no staff member ever directly asked the pseudopatients what or why they were writing.

Rosenhan concluded that a person’s diagnosis or presence in a psychiatric hospital causes

medical professionals to believe that everything that person does is related to their mental illness.
Staff in psychiatric hospitals, when observing a patient, assume that “Given that the patient is in
the hospital, he must be psychologically disturbed. And given that he is disturbed, continuous
writing must be [a] behavioral manifestation of that disturbance.”

Insane Places: The Hospital's Effect on Behavior

Rosenhan’s experiment also found that hospital staff members never assume that the
depersonalizing treatment of patients by hospital staff or the bizarre atmosphere of a psychiatric
hospital may influence the behavior of people living in the wards. Because of the bias of hospital
staff to make assumptions about the source of a patient’s emotions or behavior, “behaviors that
are stimulated by the environment are commonly misattributed to the patient’s disorder.”

During one incident observed by Rosenhan’s research team, a doctor explained to visiting
students that schizophrenic patients waited outside the cafeteria for half an hour before mealtime
because of “the oral-acquisitive nature of the syndrome.” The doctor had not considered a fact
that Rosenhan and his researchers quickly discovered: patients spend time waiting for mealtime
because “there were very few things to anticipate in a psychiatric hospital besides eating.”

Pseudopatients filled their notes with examples of staff misinterpreting the behavior of patients.
When nurses encountered patients who had become upset after being ignored or mistreated by an
attendant, the nurses instead believed that the altercation had begun because of the patient’s
mental illness and not the external influence of from the hospital environment. “Never,”
Rosenhan writes, “were the staff found to assume that one of themselves or the structure of the
hospital had anything to do with a patient’s behavior.”

In his conclusion, Dr. Rosenhan says that "it is clear that we cannot distinguish the sane from the
insane in psychiatric hospitals," and explains that the environment of a psychiatric hospital
provides ample opportunity for patients' behaviors and symptoms to be misunderstood. He is
careful not to condemn hospital staff, but states that the overall experiences of his researchers in
the hospitals were negative. Because mental illnesses are diagnosed and treated based on the
observations of mental health professionals and their interpretations of those observations, as
Rosenhan points out, situations and biases that influence these observations and interpretations
must be understood and countered if mental health care is to accurately and effectively respond to
the symptoms and conditions of patients.

Sources:

Rosenhan, David L. " On Being Sane in Insane Places," Science, Vol. 179 (Jan. 1973), 250-258.